Depression

How to treat: Quiz

• Name investigations that may be required for a patient with a first presentation of psychological disorder:

• Full blood count•Electrolytes•Liver function tests•Fasting vitamin B12 and red cell folate levels•Thyroid function tests•Serum calcium and phosphate•CT scan of head•Urine screen for substances

List common side effects of SSRI antidepressants:

>10%• Diarrhea (20-25%)• Nausea (20-25%)• Headache (20-25%)• Insomnia (20-25%)• Ejaculation disorder (10-15%) • Dizziness (10-15%)• Dry mouth (10-15%)• Fatigue (10-15%)• Somnolence (10-15%)

1-10%• Agitation (5-10%)• Anorexia (5-10%)• Constipation (5-10%)• Dyspepsia (5-10%)• Decreased libido (5-10%)• Sweating (5-10%)• Tremor (5-10%)• Vomiting (4%)

1. Harry is 10 years old. He has learning difficulties and struggles at school. His teacher is concerned because he is increasingly preoccupied, disinterested, inattentive and emotionally labile and he has few friends. He attends with his grandmother, who has been his major carer since his father died in an MVA. If he has significant depression, which ONE statement is correct?

a) He may tell you about somatic symptoms or fears and phobias rather than classic symptoms of depression

b) He is unlikely to develop bipolar illness later in life

c) In his age group, depression is more common in girls than boys

d) The chance that there is a history of major depression in his family is low, at less than 10%

2. You explain to Harry’s grandmother that you think he show signs of a significant depression. When you are discussing treatment options, which ONE statement are you most likely to make?

a) Treatment options for depression have not been as well studied in children as they have in adults

b) In Australia, SSRIs have been approved for the treatment of depression in children

c) SSRIs have been shown to lower the risk of suicide in children who have major depression

d) CBT would not be a useful modality because of Harry’s age

3. Zoe reluctantly attends with her mother. She split up with her boyfriend three months ago and has been regularly missing school. She has lost weight and is no longer interested in her friends or hobbies. You are least likely to tell her mother which ONE of the following?

a) A major depression may be causing her symptoms, as this condition occurs more commonly in adolescents than in adults

b) If she does have significant depression, her symptoms may persist for about nine months and she is at high risk of relapse

c) This episode is most likely to be a simple reaction to the break-up with her boyfriend

d) Although there are several treatment options for depression, as this is Zoe’s first episode and it relates to a specific trigger, she may be best managed by psychotherapy

4. Zoe has been having professional psychotherapy using CBT. Although she has had some minor gains, she is still unmotivated and has begun expressing some suicidal ideas. The most likely actions you would choose include which TWO of the following?

a) Begin an antidepressant and arrange with her to attend for review in a few days

b) Begin an antidepressant and reassure her that it can be stopped as soon as her symptoms improve

c) Begin an antidepressant and explain she is very likely to have full remission of her symptoms and return to normal functioning

d) Begin an antidepressant and, because of her lack of motivation and ‘slowing’, you choose an SSRI, SNRI, NRI or a RIMA

5. Zoe improves on antidepressant therapy, which she takes twice daily for three months, and is keen to stop her medication. You think compliance will become a significant issue now that she is feeling better. Which TWO management actions are you most likely to choose?

a) You decide that CBT would not help her, as it had little effect initially

b) You reach an agreement with Zoe that in another two months, she can taper off her treatment over a period of two weeks

c) You change her medication from twice-daily to once-daily dosage

d) You arrange to see her more regularly to motivate her to continue her treatment

6. Martin, 37, has a history of recurrent depression. He has taken a tricyclic antidepressant in the past, but was troubled by weight gain, sexual dysfunction, a lack of energy and poor memory. When considering medication options, which TWO statements are correct?

a) Mirtazapine may cause less sexual dysfunction than a tricyclic antidepressant

b) He should stick to his tricyclic therapy because of the safer side-effect profile

c) If early agitation and insomnia occur with some of the newer antidepressants, the symptoms can be managed by medications such as benzodiazepines

d) At doses of 75mg daily, Efexor XR would act more as an NRI

7. Martin agrees to begin therapy with an SSRI. He returns three days later complaining of a temperature, a racing pulse and sweating. You are concerned that he may have serotonin syndrome. When considering management of the serotonin syndrome, which ONE statement is incorrect?

a) The patient would be more likely to develop serotonin syndrome if he is also taking St John’s wort

b) If he has serotonin syndrome, stopping any medication that elevates serotonin will usually lead to symptom reversal in 24 hours

c) The muscular symptoms of serotonin syndrome could be treated with tramadol

d) If his symptoms are severe, a serotonin antagonist such as propranolol could used

8. Lily, 69, complains of weight loss, insomnia and lethargy. About 12 years ago she had two episodes of depression that responded well to a tricyclic antidepressant. She now requests another course of the same pills. Lily’s husband died six months ago and she has recently been found to have Parkinson’s disease. Which ONE statement about Lily’s depression is incorrect?

a) Her symptoms may be due to her Parkinson’s disease and her reaction to it, rather than a recurrence of her depression

b) A tricyclic antidepressant would be ideal for her because it worked well in the past

c) Changing her social isolation may improve her symptoms

d) Establishing that she does not have another illness, such as a thyroid dysfunction, contributing to her symptoms is important

9. Lily starts treatment with an SSRI but develops some side effects, including general malaise, agitation, tremor and insomnia. When considering her treatment which TWO statements are correct?

a) Hyponatremia could be a cause of her malaise and you should check her electrolytes

b) If Lily is a poor metaboliser of drugs, lowering her SSRI dose may lower the side effects of the medication but still retain the antidepressant effect

c) Her side effects may improve if a benzodiazepine is added in the evening

d) She would be likely to have fewer side effects if she restarted a tricyclic antidepressant

10. Lily lowers her dose of SSRI but still complains of insomnia. When considering changes to her therapy, which TWO statements are correct?

a) Changing to a noradrenergic and specific serotonergic antidepressant such as mirtazapine may improve her insomnia and any agitation

b) She would be likely to benefit from a combination of SSRI and MAOI

c) If she takes mirtazapine, she may gain weight

d) If she starts mirtazapine, she should be told that it is not known to interact with any other drugs, including alcohol